Provider Demographics
NPI:1649595950
Name:WK BOSSIER PEDIATRIC PARTNERS
Entity Type:Organization
Organization Name:WK BOSSIER PEDIATRIC PARTNERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NETWORK ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-4232
Mailing Address - Street 1:2300 HOSPITAL DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2394
Mailing Address - Country:US
Mailing Address - Phone:318-212-7883
Mailing Address - Fax:318-212-7885
Practice Address - Street 1:2300 HOSPITAL DR
Practice Address - Street 2:SUITE 120
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2394
Practice Address - Country:US
Practice Address - Phone:318-212-7883
Practice Address - Fax:318-212-7885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-30
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2102583Medicaid